Consumer Law

Knowing Your Health Insurance Rights

It’s important to know your healthcare insurance rights. In doing so, you can make the best decisions related to your health care that will save you both time and money. Under the Affordable Care Act, there are health insurance rights and protections that apply to patients regardless of whether their insurance is through the marketplace, … Continued

It’s important to know your healthcare insurance rights. In doing so, you can make the best decisions related to your health care that will save you both time and money.

Under the Affordable Care Act, there are health insurance rights and protections that apply to patients regardless of whether their insurance is through the marketplace, through their employer, or through the government. Let’s take a look at some of the basic rights and protections that you should know about when it comes to your health care coverage.

What Do Health Insurance Plans Cover?

As part of your health insurance rights, you have the right to access services that are deemed “essential health benefits.” Essential health benefits include the following:

  • Ambulatory services. These are services rendered at an outpatient care facility, not at a hospital
  • Hospitalizations including overnight stays
  • Emergency room visits
  • Preventive care services such as routine screening
  • Access to mental health and substance abuse services
  • Pediatric services that include dental and vision coverage. For adults, dental and vision coverage is not deemed an essential health benefit
  • Laboratory services
  • Rehabilitative services for injuries that require physical therapy
  • Access to prescription drugs
  • Services for expecting mothers before, during, and after their pregnancy.

Coverage Despite Pre-Existing Conditions

The health care law requires that insurance plans must cover individuals regardless of any pre-existing conditions including pregnancy and that coverage should not cost more just because of these conditions. In terms of pre-existing conditions, an insurance plan cannot do the following:

  • Deny you, charge a rate increase, or refuse to pay for necessary health benefits for a pre-existing condition that existed before your plan started.
  • Rates of your coverage cannot go up because of changes in your health.
  • Government programs including Medicaid and the Children’s Health Insurance Program (CHIP) cannot refuse or deny coverage because of your pre-existing condition.
  • Pregnancies cannot cause the price of an insurance plan to go up. After enrollment, your pregnancy and delivery are covered and with 2021 health plans, births fall under a Special Enrollment Period that allows you to enroll and make changes to your insurance outside of the standard Open Enrollment Period. 

Insurance Rate Increases 

As part of your health care rights, insurance companies are held accountable for any rate increases in one of two ways; the 80/20 rule and Rate Review. 

Rate Review is when an insurance company must go over the reasoning for rate increases of 15% or more. This mandated public explanation must happen before your premium goes up. 

The 80/20 rule also known as the Medical Loss Ratio (MLR) ensures that money paid in premiums actually goes to the cost of your healthcare. Only 20% of a premium can go to funding things like administrative budgeting, and marketing costs. If an insurance company provides services to entities that have over 50 employees, then at least 85% of premiums must be allocated for healthcare costs. Insurance companies that do not satisfy the 80/20 rule are legally obligated to provide you a rebate on your premium. 

Freedom To Choose a Care Provider

All individuals with health insurance have the privilege of choosing their health care provider so long as it is within the network. When receiving emergency room services, your insurance cannot demand a higher co-pay or form of coinsurance if the service you receive is out-of-network. Additionally, you do not need to seek approval before receiving services from an out-of-network emergency room visit.

When it comes to OB-GYN services, a referral is not needed in order to get this specialized care. The right to choose which health care provider you select for yourself or your children is not subject to grandfathered plans, or plans that were purchased before March 23, 2010. 

Access to Preventive Care

A majority of health care plans offer different forms of preventive services. Preventive services include things like routine vaccinations, different screening tests, and certain reproductive health services, like access to birth control and contraceptives. Preventive care falls under three categories: for children, for women, and for all adults. Services for preventive care must fall within your insurance company’s network and different types of services vary depending on your insurance plan. 

Health Care Access for Young Adults

For young adults under the age of 30, there’s more flexibility and greater access to health insurance. If you have had a major life event such as a marriage, losing previous health insurance, having a baby, and even relocating, you can qualify for the Special Enrollment Period which allows you to make changes outside of the annual Open Enrollment Period. if you meet the qualifications for Medicaid or the Children’s Health Insurance Program (CHIP), then you can apply for this coverage at any time.

There are also different avenues in which young adults can obtain health insurance. They include the following:

  • Enrolling in a student health plan
  • Individuals under 26 can stay on a parent’s health plan 
  • Purchasing your own insurance through the marketplace. Low-income earners may be able to save on an insurance plan through the “Catastrophic” Health Plan.
  • Enrolling in Medicaid or CHIP 

Support for Expecting Mothers

Expecting mothers have their own set of rights when it comes to healthcare insurance plans. Under most Marketplace plans, expecting mothers have the right to support and counseling if they choose to breastfeed. As part of the support, expecting mothers have access to breast pumps. Insurance providers cover the cost of a breast pump device and depending on your insurance, you can choose between different types of breast pumps. 

Some health insurance policies stipulate whether you can have a manual or electric breast pump, however. If you are renting a breast pump, there may be a stipulation of whether you can rent it before or after you give birth, and how long you can rent it for. Some medical insurance plans will require your doctor to pre-authorize necessary medical equipment and support. However, your insurance plan will usually follow the recommendation of your doctor.  

Mental Health and Substance Abuse Support  

Support for mental health and substance abuse is deemed an essential health benefit under all Marketplace plans. This means that plans should cover treatment for behavioral health including counseling and psychotherapy inpatient services for mental and behavioral health

treatment. You can’t be denied coverage if you have a pre-existing mental health or behavioral health condition. 

Additionally, plans in the marketplace cannot put a cap on annual or lifetime coverage in something known as “parity” protection. Under parity protection, any limits that are applied to behavioral and mental health services cannot be more restrictive than the limits placed on medical services.

Final Thoughts

Part of your health insurance rights is being able to call your health insurance provider and have your benefits explained to you. In doing so, you will get a more thorough understanding of what coverage applies to your specific plan. Resources including can also be an invaluable tool in knowing your health-care rights. 


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